Topic 12: Upper GI Bleed and Colorectal Cancer

blood in stool and need for occult blood test

what do “black streaks that stick to the toilet” mean

• peptic ulcer disease (PUD)

• aspirin, NSAIDs, corticosteroids

• stress-related ulcers

• Mallory-Weis tear (occurs from excessive coughing)

• stress-related mucosal disease (SRMD)

what are the common causes of UGI bleeding

profuse bright red bleeding (needs lots of pressure!)

what are signs of arterial origin of a GI bleed

bleeding has been in contact with stomach acid

what does coffee ground hematemesis mean

melena

black tarry stools that is caused by digestion of blood in the GI tract and is darker

iron and pepto bismol

what are the common causes of melena

guaiac test

what detects occult GI bleeding

stress related  mucosal disease (SRMD)

physiological stress ulcers that occur most commonly in critically ill patients, those with severe burns, trauma, or major surgery, and patients with coagulopathy on mechanical ventilation (highest risk) and can cause upper GI bleeding

endoscopy

tube inserted through the mouth and down the throat with a camera at the end to allow visualization which is the primary tool in order to diagnose upper GI bleeding, including hematemesis

• lavage (decompression) may be needed for a clearer view

• use NG or OG tube placed in room temp water or saline

• do NOT advance the tube against resistance

• stomach contents are aspirated through a large bore tube to remove clots

what are the nursing interventions before someone gets an endoscopy

angiography

diagnostic done only to diagnose when an endoscopy cannot be done as it is invasive and may not be appropriate for high risk/unstable patients; cath is placed into left gastric or superior mesenteric after insertion in femoral artery until site of bleeding is discovered

• initial Hgb may be normal and may not reflect loss until 4-6 hours after fluid replacement

• BUN may be high for a severe hemorrhage

• PT and PTT are increased

what are lab studies of someone with a GI bleed

• assess for shock

• indwelling catheter for accurate assessment of hourly output

• maintain NG patency and position

• hemodynamic monitoring

• O2

• auscultate for bowel sounds

• assess abdomen for peritonitis 

• fluids based on physical and lab findings

  • isotonic crystalloids (LR)

  • volume replacement with whole blood, PRBCs, and FFP

• place multiple large-bore IVs for fluid/blood replacement

• CVP or PAC reading every 1-2 hours

what is emergency assessment and management for a patient with a upper GI bleed

tense, rigid and board-like abdomen; needs antibiotics

what are the S/S of peritonitis

1500 mL of blood

what is considered a massive upper GI bleed

endoscopic hemostatic therapy

what is the first line therapy for a UGI bleed

mallory weiss tear (from excessive coughing)

what is endoscopic hemostatic therapy used for

surgery

what may be necessary if a patient continues to bleed after rapid transfusion of up to 2,000 mL of whole blood

• empiric PPI therapy with high dose IV bolus and subsequent infusion  before endoscopy 

• can give epi during endoscopy to stop bleeding due to ulceration 

• octreotide

what is drug therapy given for an UGI bleed

• mark the lumens

• secure the tube

• deflate balloon for 5 min every 8-12 hours to prevent necrosis

• manage airway

what are nursing interventions if a balloon tamponade is done for esophageal varices

it is of short duration

when vomit contains blood but stool does not what is considered about the hemorrhage

delirium tremens (withdrawal S/S)

if hemorrhage is a result of chronic alcohol use, what should you monitor for

keep NPO in case they need surgery 

if appendicitis is suspected who should be done with the patient 

• dull periumbilical pain

• anorexia

• N/V

• McBurney’s point

• client usually prefers to lie still, often with right leg flexed which takes pressure off

what are the S/S of appendicitis

preventing peritonitis and removing the appendix

what is treatment for appendicitis aimed at

ruptured appendix

what does it mean if pain is suddenly relived in the abdomen

• prevent fluid volume deficits from N/V

• keep NPO until HCP evaluates for surgery

• monitor VS and assess for deterioration

• relieve pain

• position for comfort

  • client usually prefers to lie still, often with right leg flexed which takes pressure off

what are nursing interventions for appendicitis

• NPO

• NG to low or intermittent suction for gastric decompression 

• semi Fowler’s

• IV fluids with electrolytes

• blood transfusions

• antibiotics, especially if appendix is ruptured

what are post op considerations after an appendectomy

peritonitis

results from a localized or generalized inflammatory process of the peritoneum

• abdominal pain and distention

• tenderness over the involved area and diffuse pain

• rebound tendernes

• abdominal muscular rigidity and spasm

• fever, tachycardia, tachypnea, N/V

what are the S/S of peritonitis

they eat more red meat and drink less water

why is colorectal cancer more common in men

onset is insidious and symptoms do not appear until disease is advanced

why is regular screening for colorectal cancer necessary

• first degree relative

• IBD

• family history

• FAP

what are RF for colorectal cancer

every year

how often do you need to get a colonoscopy if you have the FAP gene

• only appear with advanced stages of disease

• change in bowel habits

  • alternating constipation and diarrhea

  • change in caliber due to polyps or blockage

• unexplained weight loss

• vague abdominal pain, fatigue, weakness

• rectal bleeding

• sensation of incomplete evacuation

• obstruction

what are S/S of colorectal cancer

colonoscopy every 10 years

what is the gold standard for colorectal cancer screening

• flexible sigmoidoscopy

• colonoscopy

• barium enema

• fecal occult blood test

• fecal immunochemical test

• CT colonograph

• tissue biopsies

• carcinoembryonic antigen

  • no a good screening tool because of large numbers of false positives

what do screenings for colorectal cancer include

carcinoembryonic antigen (CEA)

what is not a good screen tooling for colorectal cancer due to a large number of false positive results

• polypectomy during colonoscopy

• right or left hemicolectomy

• chemo/radiation

• temporary colostomy, ostomy, J pouches

what is treatment for colorectal cancer

pink or red, little bit of bleeding, little bit of edema

what should the stoma for an ostomy/J pouch look like

call HCP, site is not getting enough blood

what should you do if a stoma is purple or dark red

will cause more of a nutritional deficiency

if someone has short bowel syndrome why do we not give them laxatives